LAPAROSCOPIC CHOLECYSTECTOMY IN EMPYEMA GALL BLADDER-ITS SAFETY AND FEASIBILITY

DrPrakash Kumar Sahoo, DrSumanSaurav Rout, DrKasturiBharadwaj, DrPriyadarsanKonar and Dr Rima Sultana. Department Of General Surgery, IMS & SUM HOSPITAL, Siksha O Anusandhan University, Bhubaneswar, Odisha, India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


ISSN: 2320-5407
Int. J. Adv. Res. 5 (10), 551-556 552 may progress to suppurative infection in which the gallbladder fills with purulent material, a condition referred to as empyema of the gallbladder.
Thortonetal suggested that "Empyema of the gall bladder was described extensively in surgical texts earlier but now receives scant mention 1 or none at all. 2 In addition, it appears to have been largely forgotten that its course can be chronic. 3 Patterns of presentation in empyema of the gall bladder may vary widely with some presenting acutely with features of sepsis, a tender palpable Gallbladder and leukocytosis while in others the course may be quite insidious and chronic due to widespread use of antibiotics or may be the immunosuppressed nature of the patient and may exhibit few signs and symptoms.
In this era of laparoscopy, the overall scope and outlook towards the treatment of gallstone disease and its complications has changed. Features suggesting the diagnosis and seriousness of a dreaded complication of Gall stone disease like Empyema of the Gallbladder are far and few. 4,5 Earlier Empyema GB was considered as a contraindication for laparoscopic cholecystectomy due to the fear of complications and being the number one cause for a conversion 6 . Increasing number of studies suggesting the relative safety of attempting laparoscopic cholecystectomies for acute cholecystitis and its complications. 7-11 Rates of conversion depend on various factors like obscured calot's anatomy, uncontrolled bleeding, injury to adjacent structures etc.The number of absolute and relative contraindications to performing laparoscopic cholecystectomy has decreased over the past 20 years as minimally invasive surgical instrumentation and skills have improved. There have been reports of patients with empyema of the gall bladder, who have presented early without significant gangrenous changes or perforation, can be treated with laparoscopic cholecystectomy.
The gallstone diseases are fairly common in this part of the country and empyema gallbladder is often encountered. We decided to aim our study to comprehensively look into the clinical profile of empyema gallbladder and the safety, feasibility and outcome of laparoscopic cholecystectomy in patients with Empyema of Gall Bladder.

Material & Methods:-
This prospective clinical study covers 69 cases of empyema of the gall bladder, which were admitted in the Department of General Surgery, Institute of Medical sciences & SUM Hospital, Bhubaneswar, Odisha, India, during the period from January 2015 to December 2016.
Institutional ethical clearance was taken prior to the conduct of the study. All those patients who has been suspected as having empyema of the gallbladder on the basis of clinical findings, preoperative ultrasonography findings and diagnosed on intraoperative aspiration of pus from gallbladder was included for this study.
After admission in the hospital, necessary particulars regarding the name, age, sex, religion and address of the patients were recorded. The patients were then studied clinically and necessary investigations were done and operation was performed after proper preoperative workup. A well informed written consent was taken from each patient prior to surgery. Laparoscopic Cholecystectomy was initially attempted in all cases. The procedure was done by standard 4 port technique. In case of thickened wall, the gallbladder was punctured and the suction cannula directly introduced into gall bladder to aspirate pus. At times the suction cannula was also used to dissect the dense adhesions in the area of Calot's triangle using continuous pressurized irrigation technique. Data of each patient was recorded in view of the operative findings, intraoperative complications, post-operative complications and duration of hospitalization.

Results:-
Age and sex distribution:-The age of the patients ranges from 22 years to 68 years. Maximum incidence was found in between the age group of 40-60 years. (Table 1) The average age for female was 46.02 years and for male was 45.5 years. In our study there is a higher incidence of disease in females with a male: female ratio of 1: 2.13.

Distribution of presenting symptoms (table 2):-
In our series pain over upper abdomen was the most consistent presenting complaint found in all the patients. Pain abdomen was mild only in 13 % of patients, others complained of moderate (46.3%) to severe (40.5%) degree of pain over right upper abdomen.Pain referred to right shoulder or the inferior angle of scapula was found in 32 % of the cases.Fever was seen as a presenting symptom in 85.5% of the cases with Nausea and vomiting was also fairly common feature (73.9%). Jaundice was present only in 17 % of patients.

Comorbidities:-
Thorough assessment of the existing co morbid condition if any of the patients was done (Table 3). In our series 26 (37.6 %) patients suffered from Diabetes mellitus type II and were either on Oral Hypoglycemic Agents or on subcutaneous Insulin regularly.7 (10.1%) of patients had Hypertension and were on anti-hypertensive drugs.3 (4.3%) patients all males had COPD while only 2 (2.8%) patients both females were on eltroxin for Hypothyroidism.

Distribution of cases in respect of examination findings:-
On examination Icterus was present only in 12 patients (17.3%). All patients had tenderness in the right hypochondrium and localized abdominal guarding was found in 55 cases (79.7%). In 45 cases (65.2%), a tender palpable lump was found in the RHC. Nearly 30 % patients presented with dehydration evident with the high colouredurine. (Table 4) Laboratory work up:-Total W.B.C. count (Table 5):-Out of 69 patients, 35 had a total WBC count between 10,000-15,000 cell/cmm (50.7%). 11 patients (15.9%) had total WBC counts <10,000cell/cmm and 16 patients (23.1%) had total WBC count >15,000cell/cmm. More than 20,000 cell/cmm total WBC count observed only in 7 patients (10.1%) Liver Function Tests:-One or more abnormal findings were found in most of the Liver Function tests profiles though none were specific.

USG findings s/o Empyema GB:-
In our series we used ultrasonography findings along with clinical judgement and laboratory values to close in on our pre operative diagnosis .Though no specific USG feature is diagnostic of Empyema GB ,the features such as distended GB with thickened edematous wall > 6mm with intraluminal sludge or calculi (80-88% ), impacted calculi in GB neck or cystic duct (71%) and some amount of pericholecystic omental adhesions and fluid collections (32%) are definitely suggestive. (Table 6) The main diagnostic criteria including clinical symptoms and signs along with Total W.B.C. count and ultrasonography findings as enumerated in Table 4, 5 and 6.
Preoperative diagnosis was established in 42(60.8%) patients while remaining 27 (39.1%) patientswere identified during surgery. All of these patients were operated laparoscopically within 48 hours of the admission. Laparoscopic Cholecystectomy were completed successfully in 66(95.6%) while in 3 (4.3%) patients the procedure was converted to Open Cholecystectomy.The reasons for conversion being discovery of a cholecysto-duodenal and cholecystocolic fistula in one patient while in the other two patients the reason for conversion being an obscure Calot's anatomy. Conversion was found more common in those who had history of repeated attacks in the past.
Various operative findings noted during each surgery was duely noted (Table 8). Dense pericholecystic adhesions from the omentum and other adjacent structures including the stomach ,duodenum and the transverse colon were very common finding (65.1%)though only 17(24.6%) cases with fluid collections were noted. Dilated Common Bile Duct was seen in 16 patients (23.1%).Calot's Anatomy was reached and dissected with difficulty in 44 cases(63.7%) while calots was completely frozen in 2 cases which were later converted to open surgery. Perforated and gangrenous Gall bladder were noted in 4 cases. A single case was encountered where we found a cholecysto gastric fistula and in the above case we could manage the case safely laparoscopically. While in another case we had to 554 convert into open surgery when we encountered a cholecysto-duodenal and cholecysto-colic fistul along with a gangrenous Gall Bladder and a relatively difficult calot's anatomy. We encountered bleeding either from the cystic artery or from the liver bed in around 9 cases (13.0%),but were managed successfully.
The overall rate of postoperative complications was 28.9% i.e 20 patients. (Table 9)There were 11 cases of port site wound infection , 4 cases of bile leak out of which 3 resolved later spontaneously while in 1 it resolved after an ERCP was done and a biliary stent was placed.2 patients had intra abdominal collections out of which one was managed conservatively while the other required a laparoscopic drainage of the collections.4 patients had lower respiratory tract infection in the post operative period.
Almost 71% of the patients i.e. 49 out of 69 were discharged with in 48-96h.In 14 patients (20.2%) the stay in hospital was extended to 7 days. While the remaining 6 patients were discharged in two weeks time. The average hospital stay in all patients was 5.1 days.

Discussion:-
Gall stone diseases are no doubt more common in female population and incidence is more between the 4 th to 6 th decade of life though reporting of Gall bladder disease has been in every age. 12,13 Indian studies have reported maximal incidence in the 4 th and 5 th decade with complications from acute cholecystitis being common in the 5 th decade and beyond. 14 In our series the focus was on Empyema Gall Bladder which was seen to occur in all ages ranging from 22 to 68 years group though the incidence is maximal between 40-60 years of age(65%) making it a disease of the elderly and immunocompromised. There is a higher incidence of disease in females with a male: female ratio of 1: 2.13.
In our series pain over upper abdomen was the most consistent presenting complaint found in all the patients. Most of our patients have moderate (46.3%) to severe (40.5%) degree of pain over right upper abdomen. Similar results were seen in studies by Tseng etal 15 and Malik etal 16 .Pain referred to right shoulder or the inferior angle of scapula was found in 32 % of the cases. Fever was seen as a presenting symptom in 85.5% of the cases with Nausea and vomiting accompanied pain in most of the cases(73.9%). Jaundice was present only in 17 % of patients.
Thorough assessment of the existing co morbid conditions revealed that 26 (37.6 %) patients suffered from Diabetes mellitus type II. We observed that though overall the distribution of DM II in the male and female groups were equal, a very high percentage (59.0 %) of males with DM II were likely to have an acute cholecystitis develop into empyema pretty early.
All patients had tenderness in the right hypochondrium and localized abdominal guarding was found in 55 cases (79.7%). In 45 cases (65.2%)a tender palpable lump was found in the RHC similar to other studies where a palpable GB was noted in 58 % cases 16 . Greater awareness of these various clinical presentations is needed to reduce the considerable morbidity and mortality caused by the delay in diagnosis.
Throtonetal had recorded raised Total WBC count in 90 % cases 2 and LFT abnormalities though none of the LFT findings were specific. Such results were even detected by Chow WC etal in 51% cases. We in our series found raised Total WBC count i.e> 10000 cells/cumm in 83 % patients. In our series we used ultrasonography findings along with clinical judgement and laboratory values to close in on our pre operative diagnosis .Though no specific USG feature is diagnostic of Empyema GB ,the features such as distended GB with thickened edematous wall > 6mm with intraluminal sludge or calculi (80-88% ), impacted calculi in GB neck or cystic duct (71%) and some amount of pericholecystic omental adhesions and fluid collections (32%) are definitely suggestive.
In this era of advancements in laparoscopic techniques and increased skill among surgeons laparoscopic cholecystectomy has become the preferable and probably acceptable choice in most of the complications of acute cholecystitis. [16][17][18][19] As was suggested by Hunter " to get it while its hot" 20 , the safety and feasibility of laparoscopic cholecystectomy has been pushed to its limits as more and more surgeons are performing them in acute cholecystitis. Very few studies have reported its safety profile in Empyema Gall Bladder.

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Laparoscopic Cholecystectomy were completed successfully in 66(95.6%) while in 3 (4.3%) patients the procedure was converted to Open Cholecystectomy. The reasons for conversion being discovery of a cholecysto-duodenal and cholecysto-colic fistula in one patient while in the other two patients the reason for conversion being an obscure Calot's anatomy. Conversion was found more common in those who had history of repeated attacks in the past.
The rate of conversion can be significantly reduced by meticulous dissection ,patience ,clear visualization and proper identification of the anatomy of calot's triangle. In case of thickened wall, the gallbladder was punctured and the suction cannula directly introduced into gall bladder to aspirate pus as was proposed by Tseng etal 15 . At times the suction cannula was also used to dissect the dense adhesions in the area of Calot's triangle using continuous pressurized irrigation technique. Injury to any of the adjacent structures can be prevented by proper visualization .The use of diathermy must be very judicious and limited.
Cox etal 21 reported a conversion rate of 83% suggested that empyema once diagnosed should be converted without much ado. However Elder etal 22 reported a much more encouraging conversion rate of around 12.5 % while Malik etal 16 reported a 19.4% conversion rate. However in our series the conversion rate was only 4.3 % .
The overall rate of postoperative complications was 28.9% which which ranges from minor port wound infection to bile leak and abdominal collection. There was no mortality in our series .Thus our study did not present us with any such life threatening complication which would dissuade the laparoscopic approach towards Empyema GB, though Surgeons should always keep in mind the possibilities while approaching such cases.

Conclusion:-
Empyema of gall bladder is not an uncommon complications of acute cholecystitis. The clinical history of a patient with empyema of gall bladder is most of the time similar to that of a patient with acute cholecystitis and should be suspected based on clinical judgment and laboratory parameters. An aggressive policy of early introduction of broad-spectrum antibiotics and cholecystectomy is the criterion standard of treatment. Laparoscopic cholecystectomy can be performed in empyema of gallbladder keeping in mind a slightly increased risk of complications. However, the technical experience of the surgeon and surgical knowhow plays a key role in the overall outcome. We can conclude from our study that laparoscopic cholecystectomy is a safe procedure and pretty much feasible in the hands of experienced surgeons.